Sometimes you don't know what you don't know. In the mid-1990s, I left my job as division director of general internal medicine at Hahnemann University School of Medicine in Philadelphia. I welcomed the challenges that would come with my new position as medical director (currently, I'm interim chief medical officer) at Horizon/Mercy, an HMO for the publicly insured in New Jersey.

Yet I had little inkling of what some of those challenges would be and how my medical training had left me unsuited to respond to them.

This became evident from the moment I sat in on my first business meeting in 1995, where the focus was on reviewing financial reports, profit and loss statements, balance sheets, strategic plans, and quality programs.

When I expressed my point of view, I didn't just leave it at that. I explained it, rephrased it, then explained it again just to make sure that everybody really understood.

This, of course, is the way many good physicians deal with patients because we know that people often don't hear things the first time.

My CEO at the time took me aside and said: "We heard what you said the first time. We heard it the second time. We even heard it the third time."

He said he wanted clear, concise, "lasered" presentations — right to the point. The assumption was that you had done your homework — long explanations were generally not required.

Many physicians who are considering career moves into the business arena mistakenly believe that, compared to clinical medicine, being an executive will be "easy."

While clinical medicine is certainly difficult and challenging, large numbers of physicians have failed to make the transition to the business world due to a fundamental lack of skills — and they are truly shocked by the difference between the reality and their preconceptions.

My CEO was aware of this disconnect, and he suggested that I could use some executive coaching. I welcomed the help. The way I saw it, even the best tennis player in the world has a coach. No matter how good you are at something, you could still benefit from the objective advice of an expert.

The higher up you are, the fewer people you have to really talk to, whereas in clinical practice, "sidewalk consults" with peers about a difficult decision, case, or issue are common. Objective expertise may not be as readily available in a business hierarchy.

Every other Tuesday

Every two weeks, usually on Tuesdays at 2 p.m., I speak to Val Williams, my executive coach. During our first conversation (in person, other meetings via telephone) we conducted an inventory of areas where I could benefit from coaching.

These included business skills such as how to do proper and useful performance reviews; approaches and language to deal with difficult issues with a boss or someone who reports to me; and getting buy-in without being repetitive. She also taught me how to get important feedback, run a successful committee meeting, and use conflict-resolution skills.

Val keeps me focused on the fact that every clinical issue also has a business side. If I want to start some program, I have to make a business argument for it.

Whenever we discuss an issue, Val redirects me with the questions: "What is the business issue here? How does this have an impact on the business?"

We also talk about specific problems that I might be having with specific people. Then the question is: "What's the best way to handle this?"

Of course, this is not unique to physicians — many, if not most people who are promoted to managerial positions due to their technical or clinical expertise, face the same difficulty.

Val and I go over various options and strategies. Then, the next time we talk, I tell her how the specific strategies had worked out.

Performance reviews

Executive coaching probably has helped me the most relative to doing performance evaluations. I believe they present some serious challenges to physician executives. Doctors like to be liked; they want to be patted on the back. They enjoy recognition and try to avoid giving critical feedback. They have not been trained to do evaluations. Again, this is true of many professionals, not just physicians.

Executive coaching has helped me develop the skills to do performance reviews. I have come to realize how crucial it is to provide fair coaching and feedback to people who report to you, so that they can improve their skills, and be more productive, which also benefits the company.

Part of this is structuring a development plan for each individual. Expectations need to be clearly understood. This needs to be done on an ongoing basis, not just once a year — the review should never come as a surprise.

I have sat in on innumerable medical departmental or staff meetings where the same issues were complained about and rehashed for months or years, without any attempt to establish a plan to deal with them.

Now, I identify specific issues, establish action plans, and set deadlines for improvement. This is something that I had always been weak at and that, I believe, physicians in general do poorly. Those kinds of things never got done in my whole experience in an academic center.

Another big area where executive coaching paid off for me is in running committees. That's a challenge because you have different people with different agendas. You always have some people who are more vocal. How do you keep them from drowning out the less vocal members? The challenge often is to get some people to listen more. Another strategy here is to ask specific committee members to give feedback to an individual.

I've also learned that good managers manage those above, as well as below, them. If I'm not happy with something my boss has done, how do I handle that? There's a whole lexicon that I needed to familiarize myself with.

For instance, I learned to avoid "you" language. Val told me that too many people barge into somebody's office and start saying "You did this" and "You did that."

Of course, the other person immediately gets defensive. If you're managing people that way, you're going to have a lot of unhappy employees. In addition, if you use that language with your boss, you may find yourself out of a job.

There are better ways of expressing dissatisfaction. For instance, you can say, "At the meeting I felt that my voice wasn't really heard. Can you suggest how I can present myself better at a meeting?" Or, "I think you run the meetings very well, but this situation came up. I felt a bit uncomfortable. I'd like to discuss it with you. Maybe you can help me work through this."

Just the phrasing helps you to manage somebody higher up when you're unhappy. As opposed to "I want to do this" and "I want to do that," the business rationale must be presented. It may be of individual benefit, but ultimately it has to make business sense.

It doesn't come easy

Because most doctors tend to be Type A personalities, they are generally quite compulsive, work extremely hard, and strive to become efficient. Even so, they have not learned how to manage people. They tend to work much better alone than in a large, hierarchical organization.

Moreover, the many management courses that are available do not, for the most part, prepare someone for the day-to-day issues that will come up. I have been quite fortunate to work for a company and chief executive officers that have recognized the importance of management and leadership training.

Having an outstanding coach has been invaluable in learning to solve problems and deal with some very difficult situations. She is a person I can count on to be supportive and help me look at complex problems from different points of view. Most importantly, I believe that our company has derived substantial benefit as a result.

Alan G. Adler, MD, MS, is the interim chief medical officer at Horizon Mercy and a member of Managed Care's editorial advisory board.

Executives have often used coaches to extend their skills

Val Williams

The way that physicians are trained is very effective for many environments: private practice, hospitals, interactions with students and patients. However, once a physician joins the staff of a managed care organization as a medical director or chief medical officer, he may find that his personal "winning formula" doesn't work anymore. Corporations have hundreds or even thousands of employees, and the physician may find himself dealing with policies and procedures, competitive peers, office politics, negotiations, and downsizing.

Business coaching has been an important tool for senior corporate executives for a long time.

Typically, "business coaches" or "executive coaches" work with high-level executives to develop leadership skills that focus on such things as strategic planning, conflict management, and staff performance.

A business coach teaches a physician how to play the game of being a successful corporate executive. Physicians are used to being the final authority with their patients. They are trained to be confident and take responsibility for decisions. Corporate executives also value authority, but it is often based on title, power, or influence.

So how does a physician master the business skills required for corporate success? Coaching is about skill development, so the physician creates specific goals and, with the coach's help, actually practices new skills on the job so that results are measurable.